This entry is our account of a study selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text

Copy title and linkSELECT AND COPY TEXT BELOWUniversal screening for alcohol problems in primary care fails in Denmark and no longer on UK agendahttps://findings.org.uk/PHP/dl.php?file=GP_BI.nug&s=eb&sf=sfnosCLOSE
| Comment/query | Tweet

Universal screening for alcohol
problems in primary care fails in Denmark and no longer on UK agenda

No reductions in drinking were found in a Danish attempt to implement in
'real-world' conditions the primary care screening and brief intervention
protocol for heavy drinkers which emerged from World Health Organization (WHO)
trials, also the origin of a model officially recommended for England. Findings
suggest it was right for UK policy to turn away from universal screening but
whether the favoured alternative – targeted screening – will prove effective and
cost-effective or deliver public health benefits remains unclear.

FINDINGS
Of the 426 GPs invited to join the
featured study,1 39 did so. Each was required
to have practice staff to recruit patients for the study and hand them a
screening questionnaire for completion in private in the waiting room. This
consisted of the 10-item AUDIT screening test plus questions about how much the
patient usually drank. Patients were also given a survey to be completed at home
assessing how much they had drunk in the past week.

Of the nearly 7000 patients who agreed to join the study, a randomly selected
half (the control group) simply dropped their sealed screens in to a
ballot-style box and saw the doctor in the normal way, who was unaware of their
scores. The other half handed their questionnaires to the doctor who scored the
AUDIT tests. About 1 in 6 scored high enough to be considered hazardous or
harmful alcohol drinkers. Of these, about 13% were eliminated from the study
because they might actually be dependent on alcohol.

The remaining risky but presumed non-dependent drinkers – about 1 in 8 of all
the screened patients – were to be given the 10-minute intervention consisting
of feedback on their scores, advice on cutting back, a self-help booklet, and a
suggested further consultation (which fewer than a fifth returned for).
Follow-up data sought a year later from these 442 patients was compared with
that from their 464 counterparts in the control group to assess whether the
doctor's advice had curbed their drinking. Data was collected by means of a
further AUDIT test and alcohol consumption survey mailed to patients, to which
about 60% responded.

IN CONTEXT
The featured study 'seamlessly' combined AUDIT-based screening with brief
intervention during the same visit and was exclusively conducted in GP
practices, making it a close test of the recommendations which emerged from the
WHO study.3

One concern is that heavier drinkers were excluded or disproportionately lost
to the study. Nearly 8 in 10 patients who did participate denied usually
drinking amounts in excess of Danish guidelines. Comparison against these
guidelines risked validating their drinking. Heavier drinkers might have seemed
a more legitimate target and (as one
review found) might also have responded better.4
On the other hand, initial drinking averaged about 26 UK units a week and
patients with higher AUDIT scores did not respond better to the intervention.

The large loss to follow up (especially among intervention patients) is a
significant weakness but one likely if anything to have tipped the balance in
favour of the intervention.

Defensive reactions to the intervention might account for this extra loss and
for the rejection of further counselling. Such reactions were noted by the
doctors during
'debriefing' sessions.5 The doctors
themselves seemed deeply uncomfortable with the intervention, fearing that
doctor-patient rapport would be damaged by introducing drinking 'artificially'
when the patient was attending for some other reason and without a naturally
emerging clinical prompt. Despite the likelihood that the GPs who volunteered
for the study were highly motivated, almost universally they said they would not
carry on screening.

Recent
meta-analyses
combining the results of similar studies have concluded that once patients reach
the point of being randomised to receive a brief intervention, compared to
screening alone or screening plus usual care, this leads to a reduction of about
5 UK units a week in their drinking, noticeable at least a year after the
intervention.46

However, the great majority of screened patients never reach this point
because they do not score as risky drinkers, are unavailable, excluded by
research criteria, or fail to participate, leading to
an estimate that on average 1000 patients have to be screened to gain 12
months later just two or three who have stopped drinking excessively.7
Outside a research context when (as in the featured study) intervention can
seamlessly follow a positive screen, attrition might be less.

Screening too is rarely applied to more than a small minority of patients.
Initiatives like practice visits and training, especially when combined with
ongoing support, do
modestly improve screening rate and intervention rates,8
but these remain low.

In Britain at least
two
studies have found that primary care brief intervention did reduce drinking.9
10 They demonstrated the approach's potential, but not necessarily
that it would work in typical practices which themselves identified
patients for intervention, and with patients not subject to the multiple
selection gateways applied by the studies.

Perhaps importantly, in both patients were selected explicitly on the basis
of excessive consumption and either no ceiling or a very high one was set before
they were excluded. The result was a sample of on average clearly excessive
drinkers (the men averaged over 60 UK units or 480g of alcohol a week). Most
would have been towards the far end of the national distribution against which
their drinking was compared during the intervention.

Other British effectiveness studies (see
background notes for citations) were either not reflective of primary care
or inconclusive about the benefits of intervention. Feedback from staff and the
sometimes very low rates of screening and intervention suggested lack of
enthusiasm and/or of resources (such as skills, time and organisational support)
for screening and intervention, but this may have been partly due to the burden
of the associated research.

Further UK studies have minimised this burden, but even in willing practices
offered training and ongoing support, the results confirm that attempts at
universal screening (and in respect of nurses, opportunistic screening too)
result in only a small fraction of risky drinkers being advised about their
drinking.

Most practices never reach this point because they refuse screening or fail
to implement it. As in Denmark, generally nurses and doctors are prepared to
screen (if at all) only when this emerges naturally in the course of addressing
the patient's complaint or because it is a logical component of a procedure
applied to all patients in certain categories, such as those undergoing general
health checks, new patients, and patients being monitored for chronic conditions
which might be related to or aggravated by drinking.

PRACTICE
IMPLICATIONS The featured study and related British studies suggest that
universal screening for risky drinking is not feasible in normal primary care
practice. An alternative model emerging from the research as possibly feasible
and effective involves targeted/selective screening using AUDIT or shorter
screens as part of overall health checks, or when the patient's complaint might
be related to or aggravated by heavy drinking (either individually or routinely
at clinics dealing with such complaints), and then offering brief advice to
risky drinkers. What that advice best consists of is unclear.

Selective screening and typical and promising intervention approaches have
been codified in a protocol called
How much is too much?,11
recommended in
English guidelines for commissioning such work from GPs as an enhanced
service.12 'Enhanced' status means GPs are not
required to undertake this work unless they have agreed to do so under contract
to their local health authority, and authorities are not required to ensure its
provision in their areas.

England's national alcohol charity believes this option
will be taken up by only a small proportion of GPs.13
Selective screening may also mean few patients are screened. The combination
seems likely to undermine the hoped-for public health benefits of a mass
programme identifying 'hidden' risky drinking before it becomes noticeable in
drink-related complaints, though individual patients who
are screened and advised may benefit.

Thanks for their comments on this entry in draft to
Anders Beich of the University of Copenhagen. Commentators bear no
responsibility for the text including the interpretations and any remaining
errors.

2 Usual amount, amount in previous week,
reduction below excess drinking levels, ceased binge drinking, reversion to
below AUDIT risky drinking score, or at least one of the last three without
deterioration on the other two.